2 OVERVIEW BACKGROUND : AS-EPIDEMIOLOGY?MANAGEMENT OF AORTIC STENOSIS AND ROLE OF TAVITHE ADVENT OF TAVICURRENT DATA AND EVIDENCE FOR TAVITAVI- HARDWARE, PLANNING and PROCEDUREPROS & CONS OF TAVIADVANCES IN TAVITHE FUTURE FOR TAVI

5 BACKGROUND: Population explosion and AS-Indian male ~ 67yearsIndian female ~ 70 years(Kerala: ~75 and ~79 yrs resp.)-India has ~100 Million in population >60 years 3(9% of total) ~ 5 million AS !!! 1>1/3 of severe AS not suitable for SxAortic stenosis. Indian Heart Journal 2009.UN data on world population 2013Indian population statistics 2014

15 PARTNER Cohort A results30 day mortality-3.4% vs 6.5%2years:- Mortality : 34% for TAVI vs 35% SAVR- no difference in MACCESimilar benefits in hemodynamics and NYHANo difference in stroke at 2yearsMore paravalvular leak for TAVI leading to higher late mortalityMore vascular complications (11% vs 3%)Major bleeding and AF higher for SAVRBetter quality of life for TAVIFemales had mortality benefit in TAVI cohort (JACC April 2014)

24 COREVALVE RE-VALVING SYSTEM (Medtronic, Minneapolis)A trileaflet porcine pericardial bioprosthetic valveMounted in a multilevel self-expanding Nitinol frameUpper third- low radial force - sits in the ascending aorta so as to orient the valve into the aortic rootMiddle third - high hoop strength (valve attached here)Lower third- high radial strength- sits in the LVOT --has a skirt of pericardium that seals the systemNitionol: memory, expansion to predetremined sizes, more malleble at cool, firm and strong when warm

26 TAVI selection criteriaPatient and prosthesis selection are crucial in determining outcomesHEART TEAM: Cardiologist, CVTS, cardio-radiologists, cardiac-anaesthetistsPatient selection: STS score >10% / Logistic Euroscore >20%/ severe risk factors not covered by risk-scores2TAVR is acceptable only in severe AS patients with1) a life expectancy of >1 year, and2) those with a chance of “survival with benefit” of >25% at 2 years3) favourable anatomy for TAVI1.Al-lamee et al. TAVI: Current principles of patient and technique selection and the future. Circulation 2011.2. TAVI for patients with aortic stenosis: a position statement from EACTS and the ESC, in collaboration with the EAPCI.Eur Heart J. 2008;29:1463–147

39 Economic impact and quality of life?Quality of life is significantly more for femoral TAVR patientsFemoral TAVR had better economic savings and QALYs compared to SAVR at 1 year1Initial costs are however very high!!!1. Cost analysis of TAVR vs SAVR from Partner Cohort A, JACC 2012

65 ConclusionHEART-TEAM concept is supreme : Weigh evidence and choose the best in concordance to the wishes of our patientTAVI is now proven superior to SAVR in high-risk cohorts.Optimism is in the air: 1st TAVR in India(Feb 2011)TAVI can be a true success once we identify people that may die due to AS from the group that may die with AS

66 Sometimes, “it is more important to know what sort of a person has a disease than to know what sort of a disease a person has.” (Hippocrates)THANK YOU